What are safe over-the-counter (OTC) appetite suppressants?

Over-the-Counter Appetite Suppressants

Orlistat 60 mg (available OTC) is the only FDA-approved over-the-counter appetite suppressant, though it provides modest weight loss (2.8-4.8%) and recent guidelines conditionally recommend against its use due to limited efficacy and frequent gastrointestinal side effects. 1

Primary OTC Option

Orlistat 60 mg is the sole FDA-approved OTC medication for weight management:

• Mechanism: Lipase inhibitor that blocks absorption of dietary fat by preventing triglyceride hydrolysis 1
• Expected weight loss: 2.8-4.8% mean weight loss, with 3.1% at 1 year in clinical trials 1
• Dosing: 60 mg three times daily with meals containing fat 1
• Common side effects: Flatulence, steatorrhea, oily spotting, fecal urgency, and diarrhea occur frequently 1
• Critical requirement: Patients must take a multivitamin containing vitamins A, D, E, and K at least 2 hours apart from orlistat due to malabsorption risk 1

Clinical Context and Limitations

Recent American Gastroenterological Association guidelines conditionally recommend against orlistat use given its modest weight loss profile and high rate of gastrointestinal adverse effects 1. However, it may be appropriate for specific patients when:

• Other prescription antiobesity medications are contraindicated 1
• Prescription medications are unavailable or unaffordable 1
• Patients have hypercholesterolemia and can limit dietary fat intake 1

Important Contraindications

Orlistat should be avoided in patients with:

• Chronic malabsorption syndromes 1
• Cholestasis 1
• Gastrointestinal conditions predisposing to GI upset or diarrhea 1
• Inability to modify dietary fat content 1

Drug Interactions

• Cyclosporine: Potential malabsorption 1
• Thyroid hormone: Reduced absorption 1
• Anticonvulsants: Decreased efficacy 1
• Warfarin: Altered anticoagulation 1

Critical Pitfalls

• Unrealistic expectations: Patients must understand that orlistat produces only modest weight loss (typically 3-5% of body weight) 1
• Adherence challenges: The frequent gastrointestinal side effects lead to poor medication adherence 1
• Dietary modification required: Orlistat is ineffective without concurrent reduction in dietary fat intake 1
• Not a standalone therapy: Must be combined with lifestyle modification including reduced-calorie diet and increased physical activity 1

Alternative Considerations

While not OTC, patients seeking appetite suppression may benefit from discussing prescription options with their physician, including:

• GLP-1 receptor agonists (liraglutide 3.0 mg, semaglutide 2.4 mg) for superior weight loss (6-8%) 1
• Phentermine for short-term use (12 weeks) if no cardiovascular contraindications exist 1
• Naltrexone/bupropion for patients with comorbid depression or food cravings 1